DRG Coding Advisor: Coding consistency should be HIM focus, AHIMA says

Health care providers should follow the same rules

One of the biggest challenges facing the medical coding industry is making medical code sets consistent with rules and conventions that are followed by all health care providers.

"Payer-specific guidelines are not consistent with nationally recognized guidelines, and we want everyone to operate off the same set of guidelines," says Susan N. Postal, MBA, RHIA, vice president for health information management services for HCA of Nashville, TN. Postal is the 2002 chair of the Coding Policy and Strategy Committee of the American Health Information Management Association (AHIMA) of Chicago.

The current problem results from a clash between why coding classification systems were developed and how they are being used, Postal explains.

"Coding has become one of the components for how reimbursement is determined, and that’s what led to some of the confusion," Postal says. "As coding was used years and years ago, it was for statistical purposes and data purposes; now it’s also used to reimburse providers."

Another factor is that providers can’t use coding systems consistently within their own organizations because, depending on payers, there may be different guidelines, Postal says.

AHIMA recommends that all payers and providers be required to adhere to existing code set rules, definitions, and guidelines. In recent testimony to the National Committee on Vital and Health Statistics Standards and Security subcommittee, Sue Prophet, AHIMA director of coding policy and compliance, outlined the problems with current coding sets.

"ICD-9-CM lacks sufficient clinical detail to describe the severity or complexity of diagnoses, and does not provide sufficient codes for healthcare encounters for reasons other than treatment of disease, such as preventive medicine or aftercare," Prophet told the committee on Feb. 6.

Prophet explained that the ICD-9-CM is more than 20 years old and has become outdated and obsolete because its classification of some conditions is inconsistent with current medical knowledge.

Likewise, the CPT system has major flaws. "Many CPT codes are imprecise and ambiguous, failing to provide the desired level of specificity and detail regarding the service performed," Prophet told the subcommittee.

Each coding system currently used has problems, and the solution is to require uniformity and consistency of all health care organizations, payers, and other data users, Prophet said. 

"To achieve accurate and complete coded data and health information that supports this country’s health care services, research, and so forth, health care providers, health plans, and other organizations must uniformly subscribe to the same coding guidelines and practices, regardless of the level or site of healthcare service, or the method of reimbursement," Prophet told the NCVHS.

AHIMA seeks to take a leadership role in working with the government and other groups to develop standards and guidelines, Postal says.

"I think that people are committed to doing the right things the right way, and people need consistent guidelines and consistent direction," she says.

"The technology and industry are advancing, the payment systems are becoming more complex, and the classification systems need to be updated," Postal adds. "So we need to move to one procedural classification system."